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Cultural Competent Health Care

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Cultural Competent Health Care Chia-Ling Mao * Cultural safety - trust, and therapeutic Rs Respect the pt as an unique individual with needs which are influenced by ... – PowerPoint PPT presentation

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Title: Cultural Competent Health Care


1
Cultural Competent Health Care
  • Chia-Ling Mao

2
Challenges in todays health care system
  • Diverse public
  • Health care disparities
  • Key terms in todays health care environment
  • Competence, outcomes, regulation, cost
    containment, and care management
  • Highly variable approaches to health care
  • Reshaping health care system must embrace health
    promotion

3
Shrink the Earths Population to 100
  • 57 Asians
  • 21 Europeans
  • 14 North, Central and South Americans
  • 8 Africans
  • 70 would be non-white, 30 white
  • 70 would be non-Christian, 30 Christian

4
Steadily increasing diversity in the U.S.
  • Year 2000
  • Whites 69.4
  • Black 12.7
  • Hispanic 12.6
  • Asian 3.8
  • Year 2050
  • Whites 50
  • Black 14.6
  • Hispanic 24.4
  • Asian 8

US Census Bureau, 2004
5
Registered Nurses in the U.S.(2000)
  • 86.6 - non-Hispanic white
  • 10 are from racial/ethnic minority background

(US dept of Health Human Service, 2003)
6
Population in San Jose (2000)
  • Whites - 47.5
  • Hispanic - 30.2
  • Asian - 26.9
  • Black - 3.5
  • U.S. Census Bureau (2006)

7
Languages speak in U.S
  • Number of bi- or multilingual population - nearly
    50 million
  • 2005 Census Bureau American Community Survey
  • 80 - speak English
  • 12 -speak Spanish
  • 4 - speak other Indo-European languages, ie
    French, German, and Russian

8
Preparation for the future
  • Shift paradigm from illness perspective to
    supporting a health ideal
  • Health has been seen as part of an illness
    continuum
  • Shift to viewing client systems through the lens
    of health promotion and allow for different
    interpretation of client patterns, needs and
    system responses

9
Languages speak globally
  • Central Intelligence Agencys World Fact book for
    2007
  • 5 speak Spanish
  • 4.9 speak English
  • 14 speak Mandarin Chinese
  • Need for second or third language within 20 years

10
Minorities receive Lower Quality Health Care than
Whites
  • Institute of Medicine (IOM), 100 studies reviewed
    over past 10 yrs.
  • Full report www.nap.edu/books/030908265X/html
  • Minorities less likely to receive sophisticated
    Txs for AIDS
  • More likely to have leg amputations for diabetes
  • Poorer relationships with MDs

11
Other Cultural Domains
  • Folk beliefs/religion - can be confused with
    religiosity
  • Stereotyping labels - avoid generalizations
  • Ethnopharmacology - genetic influence, effect,
    metabolism
  • Herbal therapies - interactions with meds
  • Folk healers treatment approaches, e.g..,
    hysteria, psychosis

12
Integrative medicine challenge
  • Integration of conventional, complementary and
    alternative medicine (CAM) therapies
  • Public more critical of conventional therapies
  • CAM growing in popularity
  • Little collaboration

13
Cultural competence impact on clinical outcomes
  • Patients fear of being misunderstood or
    disrespected
  • Providers are not familiar with the prevalence of
    conditions among certain minority groups
  • Providers may fail to take into account differing
    responses to medication
  • Providers may lack knowledge about traditional
    remedies, leading to harmful drug interactions
  • Patients may not adhere to medical advice because
    they do not understand or do not trust the
    provider
  • Providers may order more or fewer diagnostic
    tests for patients of different cultural
    backgrounds

14
Ethnic disparities in health care
  • African American women are more likely than
    European American women to die from breast
    cancer, despite having a lower incidence of the
    disease.
  • Infant mortality rates are 2.5 times greater for
    African Americans and 1.5times greater for Native
    Americans than for European Americans.
  • Influenza death rates are higher for African
    Americans and American Indian/Alaska
    Natives/Native Alaskans than they are for
    European Americans.
  • Mortality for colorectal cancer is highest for
    African Americans, followed by Native Alaskans,
    and then Hawaiians.

15
Needs for cultural competence
  • American nurses experienced a lack of cultural
    confidence in caring for culturally diverse
    populations - Coffman, Shellman, Bernal (2004)
    and Hagman (2006)
  • There were gaps in healthcare providers
    knowledge of other cultures and how to care for
    them in culturally sensitive ways - Jones, Cason,
    and Bond (2004)

16
Other evidences
  • Negative racial stereotypes - rate black patients
    as more likely to abuse drugs and alcohol, less
    likely to comply with medical advice, and less
    likely to participate in cardiac rehab than white
    patients - Van Ryn and Burke (2000)
  • Less Dx test - physicians were less likely to
    recommend catheterization procedures for black
    female patients than white or black male patients
    if they experienced the same kind of symptoms.
    Schulman et al. (1999)

17
Cultural competence is a process
  • American Nurses Association published its first
    guidelines on cultural diversity in nursing
    curricula in 1986 - understanding the concept of
    human diversity including cultural and racial
    variations
  • The Board of Registered Nursing of California
    (2006) has required all nursing schools in
    California to include cultural diversity and
    competence into their curricula

18
Health Disparities
  • President Clinton (1998) set the goal reduce
    health disparities by the year 2010.
  • Target areas (NIH, 2003)
  • Infant mortality,
  • Cancer screening and management,
  • Cardiovascular disease,
  • Diabetes,
  • HIV/AIDS,
  • Immunization

19
Problems with Health Disparities- with cultural
factors
  • Flaskerud, J. et al (2002) a review of 79
    articles in the past 5 decades
  • Ignorance of certain groups (indigenous peoples)
  • Inappropriate lump together ie. Hispanic members
    of disparate groups with their own cultural
    identity eg., Puerto Ricans, Mexicans, Cubans,
    Dominicans

20
Adays 2010 Priorities Showcase Needs within
vulnerable population
  • High-risk mothers infants-of-concern
  • Chronically ill disabled
  • Persons living with HIV/AIDS
  • Mentally ill disabled
  • Alcohol other substance abuses
  • Suicide- or homicide-prone behavior
  • Abusive families
  • Homeless persons,
  • Immigrants/refugees

21
Impact of Cultural Competency
  • More successful patient education
  • Increases in pts health care seeking behavior
  • More appropriate testing and screening
  • Fewer diagnostic errors.
  • Avoidance of drug complications
  • Greater adherence to medical advice
  • Expanded choices and access to high-quality
    clinicians.

22
Culture - Bound Syndromes
  • A person living within a certain reality
  • Learned way to interpret the world based on
    enculturation
  • Recurrent, locality- specific patterns of
    aberrant behavior and troubling experiences that
    may not be linked to a DSM-IV diagnosis

23
Culture Bound Syndromes
Group Disorder Explanation
Caucasian Anorexia Preoccupied body wt. image
Nervosa Bulimia Binge eating followed by vomiting
African American Low blood Insufficient blood or weakness of blood
High blood Blood that is too rich
Thin blood Susceptibility to illness
24
Culture Bound Syndromes Cont.
Group Disorder Explanation
Chinese/ Southeast Asian Koro Fear that penis is retracting into body
Amok Acute reaction to loss,
25
Culture Bound Syndromes Cont.
Hispanic Disorder Explanation
Empacho Food clings stomach intestines pain
Mal ojo evil eye Strangers attention causes illness in children
Susto Anxiety, phobias
26
Culture Bound Syndromes Cont.
Group Disorder Explanation
Native American Ghost Hallucinations, terror
Japanese Wagamama Childish behavior
Korean Hwa-Byung Multiple somatic psychological symptoms
Cambodian Koucharang thinking too much Headaches, chest pain, palpitations, SOB, insomnia
27
Culturally and Linguistically Appropriate Service
(CLAS)
  • Published in the Federal Register in Dec. 2000
  • Basis for government and private sector
    activities to define, implement, and evaluate
    cultural competence activities among health care
    providers
  • Ideally supported by research

28
CLAS standards
  • 14 standards are organized by themes
  • Culturally competent care (standards 1-3)
  • Language access services (standards 4-7)
  • Organizational supports for cultural competence
    (standards 8-14)
  • 3 types of standards of varying stringency
    mandates (st. 4-7), guidelines (st.
    1,2,3,8,9,10,11,12,13), and recommendations (st.
    14)

29
Three areas of focus for improving CLAS
  • Providing linguistic services (oral and written)
  • Improving cultural competence
  • Developing a diverse workforce

30
Cultural competence research
  • Quality control
  • Regulators and standards setters
  • Designers of cultural competence intervention
  • Standard definitions for cultural competence
    research

31
Cultural competent intervention
  • How does it affect patient, family and staffs
    utilization of services
  • Comprehension
  • Satisfaction
  • Adherence to medication
  • Lifestyle recommendations
  • Appropriate utilization
  • How to demonstrate culturally competent reduces
    cost and improves health (due to many confounding
    variables).

32
Other evaluations
  • How does cultural competence contribute to
  • Access and outcomes
  • Quality and reduction in errors
  • Cost
  • Comparative analysis what works best under what
    circumstances

33
Key concepts
  • Many approaches to bridge communication barriers
    stemming from
  • Racial, ethical, cultural and linguistic
    differenced
  • Cultural competence included
  • Interpersonal aspects
  • Organizational strategies

34
Equal access to treatment and care
  • Ethnicity
  • racial discrimination,
  • racial harassment and
  • oppression
  • Secondary problems
  • stress
  • psychological trauma

35
Cultural needs Narayanasamy, 2003
  • Equal access to treatment and care
  • Respect for cultural beliefs and practices
  • religious
  • Dietary, personal care needs, daily routines,
  • Dying needs
  • Communication needs,
  • Cultural safety needs

36
Language barriers and disparity
  • Utilization of health care services
  • Fewer doctor visit and less preventive services
  • More diagnostic test to compensate communication
    problems
  • Satisfaction
  • Less satisfied unless with interpreter
  • Adherence
  • Miss the appointment or drop out
  • Outcomes
  • Patient education

37
Temporal Relations
  • Time Orientation
  • Past, present or future-oriented
  • Punctuality

38
Communication needs
  • Barrier
  • Impede early detection
  • delay prompt treatment and care
  • Forms
  • Language
  • Non-verbal communication
  • Translation services
  • Interpreters
  • Family interpreters

39
Cultural safety needs
  • Engage clients as partners
  • Respect rapport -gt self-esteem
  • Cultural negotiation culture compromise

40
Transcultural Care Practice
  • Initiative
  • Enthusiasm
  • Commitment of individuals and groups
  • Strategic planning
  • Organization coordination of services
  • Funding
  • Education
  • Recruitment research

41
ACCESS Model Narayanasamy, 2002
  • Assessment
  • Communication
  • Culture negotiation and compromise
  • Establishing respect and rapport
  • Sensitivity
  • Safety

42
Campinha-Bacotes Cultural Competence Model
  • Cultural awareness
  • Cultural skill
  • Cultural knowledge
  • Cultural encounters
  • Cultural desire

43
Purnells Model
  • Macro level global society, community, family,
    individual, health
  • Cultural domains overview, communication,
    family roles, workforce issues, bioculturl
    ecology, high-risk behaviors, nutrition,
    pregnancy childbearing practices, death
    rituals, spirituality, health care
    practice/practitioners
  • Cultural consciousness
  • Unknown phenomenon

44
Negotiation Process
  • Listen to the clients perspective
  • Teach from your knowledge in language
    appropriate for client family
  • Compare similarities differences, disagree but
    do not devalue clients view
  • Compromise
  • if client treatment not harmful, promote
  • If harmful, explain harm and suggest alternatives

45
Culturally Competent Organization
  • US Census Bureau, 2000 total population
    281,421,906
  • Latio 35.5 million 12.1
  • African American 12.9
  • Asians 4.2 (60 is foreign
    born)
  • Multiracial 2.4
  • Ethnic minorities accounts for one fourth of the
    nations population
  • In 2020, it will be near to 40
  • 10 of RNs in the US are from racial/ethnic
    minority background (2000)

46
Organizational self assessment for culturally
competent care
  • Assess attitudes, beliefs, practices, policies,
    and structures
  • Includes meaningful involvement of consumers,
    community stakeholders and key constituencies
  • Must be non-judgmental
  • Results are used to enhance and build capacity
  • Must widely disseminate through diverse
    strategies
  • Must use a strength-based approach
  • Problem-focused correct deficits, short-tem
    impact
  • Strength-based build strengths resources,
    long-term impact

47
Organizational Diversity Competence
Model(Frusti, Niesen, Campion, 2003)
Drivers
measurements
Linkages
Commitment
Culture
48
Embracing Diversity
49
Ladder of inference
  • Action
  • Feeling emotion
  • Beliefs and attitude
  • Perception assumptions

50
Similarity Vs. Differences
  • Assumptions truth
  • Inherited traits
  • Ways of capture, store, retrieve information
  • More likely when time information are limited
  • Subconsciously discriminate
  • Race gt gender gt age

51
Stereotypes
  • Mental shortcut
  • Based on limited knowledge/experience
  • More likely
  • Multitasking
  • Anxious
  • Have to make quick decision
  • Pressed for time
  • generalization

52
Generalization
  • Based on common trends among groups
  • Need information to determine if person fits the
    group/category
  • It is a starting point

53
Challenges
  • Language barrier
  • Accents, slang, dialects, familiarity with
    English, speed
  • Literary barriers
  • Different belief or perceptions
  • Culture
  • Decision maker/communication roles, communication
    styles, culture values
  • Trust

54
Culture and communication
  • High context ....Low context
  • Egalitarian ... Hierarchical
  • Individualist ...collectivist
  • Relationship .Task
  • Monochronic .polychronic
  • Harmony .. differences

55
Strategies to embrace diversity
  • What have worked ?
  • What has not worked ?
  • Individual level
  • Organization level

56
Reasons for embracing diversity
  • Individual reason
  • Unit reason
  • Organization reason

57
Discussion
  • How diversity can promote partnership and shape
    conflict?
  • Strategies for improving cross-cultural
    communication?
  • Is it a heart work, head work, or hand work?

58
Before Next Class
  • Take extra care of yourself and your family
  • Presentation list is posted at D2L
  • Pick your group and the topic for group
    presentation. If you have ppt, send it to
    atn_at_sjsu.edu one week before your presentation
    limit slides to 30
  • Have a great week

59
The End
60
The Health Promotion Matrix
Gorin, S. Arnold, J. (1998). Health Promotion
Handbook. St Louis Mosby. P 92
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